Synopsis In the morning, while the Pacmonarch lay at anchor, the crew began launching the port lifeboat for a run ashore. The lifeboat was of the davit launched, totally enclosed type and fitted with on-load release hooks. Four crew members boarded the lifeboat while two others on the ship removed the securing pins at the davits to prepare for the launch. Soon after the davits hit their stops and the lifeboat was about 15m above the sea, the after hook separated from the after suspension ring of the falls. Suspended from the forward hook, the lifeboat swung almost vertical, at which point the forward hook opened. Completely free, the lifeboat fell stern first into the sea. Three of the four people in the lifeboat were fatally injured. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The Pacmonarch was built in July2000 in Sasebo, Japan, as a panamax, gearless, dry bulk cargo vessel. It has seven cargo holds. The wheelhouse, the accommodation block, and the engine room are at the after end of the ship, abaft the seventh cargo hold. Outboard of the accommodation block, the vessel carries two lifeboats: one on the port side and one on the starboard side. 1.1.2 Description of the Lifeboats The lifeboats, 5.33m long with a beam of 2.49m, are constructed of glass-reinforced plastic and are totally enclosed and self-righting. The lifeboats are made in two sections: the canopy and the hull. Both sections are bolted together to form a watertight seal at the hull-to-canopy joint. The lifeboats each have a net weight of about 1670kg and a total gross weight (including personnel, equipment, fuel, and sundries) of about 3870kg. They are designed to carry a maximum of 25persons each and are designed, constructed, and equipped according to the International Convention for the Safety of Life at Sea, 1974 (SOLAS). Figure1. View of davit, showing lifeboat in the stowed and swung-out positions 1. Winch-brake remote-release cable, 2. Sheave, 3. Horn on davit, 4. Floating block, 5. Davit, 6. Suspension ring, 7. Bollard on lifeboat, 8. Gripe, 9. Falls, 10. Winch-brake handle, 11. Winch drum, 12. Davit hinge. Figure2. View of davits and side of lifeboat in the stowed position 1. Winch drum, 2. Electric motor, 3. Falls, 4. Sheaves, 5. Entrance hatch, 6. Harbour pins, 7. Lifeboat, 8. Davit head, 9. Winch-brake remote-release cable, 10. Forward horizontal bollard, 11. Embarkation platform, 12. Davit, 13. Davit hinge, 14. Skid. Photo1. Davit heads and outboard side of lifeboat. Photo2. Entry hatch and inboard side of lifeboat. The internal layout and configuration are typical of most modern, totally enclosed lifeboats. Seating is arranged fore and aft on either side and along the centreline. Crew members sit facing each other and secure themselves by wearing safety harnesses and seatbelts. The coxswain's seat is at the stern. It is raised to permit all-round vision from a conning tower built into the after, top portion of the canopy. All of the lifeboat's controls - the steering wheel, engine throttle, clutch, and winch-brake remote-release cable (see Figure 2, Item 9) - are accessible from this position, as is the central hook release handle (Photograph 12). This lever is fitted to the after bulkhead of the canopy and is situated aft and to port of the coxswain's seat. Each lifeboat is powered by an inboard diesel engine that drives a fixed-pitch propeller. Steering is by means of a controllable Kort nozzle. 1.1.3 Davits, Winch, and Support Structure The ship has two sets of steel davits - one on each side - on the first accommodation deck above the main weather deck. The davits form part of a steel cradle and framework that is welded to the deck. The davits are of the luffing type: they swing out by gravity and pivot on a hinged pin. In the stowed position, two harbour pins (cradle clamps) prevent the davits from accidentally swinging out. Photo3. 1. Davit, 2. Falls, 3.Embarkationplatform, 4.Frame Photo4. 1.Davit head, 2.Horn, 3.Eyeinfloatingdock, 4.Suspensionring An electric winch is bolted to the after support frame. The winch carries two drums around which the continuous-wire falls wind. Via a system of sheaves and pulleys, the falls pass through two floating blocks to which two suspension rings are shackled. Each lifeboat has two permanently attached lifting hooks, one at each end. The hooks pass through these suspension rings, thus attaching the lifeboat to the falls. The electric winch has a unidirectional freewheeling clutch and a brake that is activated by a weighted dead man's handle. This handle is also connected to the winch-brake remote-release cable (seeFigure2,Item9), which passes through another set of sheaves and into the conning tower of the lifeboat, ending within easy reach of the coxswain. The lifeboat is not designed to be bowsed alongside and is not equipped with bowsing tackle or tricing pendants. Photo5. 1. Frame, 2.Gripe, 3.Dead man's handle (winch brake), 4.Winch drum Photo6. After view of lifeboat, showing davit, gripe arrangement around bollards, suspension ring, hook, and hatch 1.1.4 Bollards and Gripes Two horizontal bollards are fixed to the lifeboat's hull, one at each end of the lifeboat. Circular guard plates are welded to the ends of the bollards. The base plate of the after bollard is flat and is inwardly inclined at 2 to the vertical; the base plate of the forward bollard is radiused and inwardly inclined at 7.5 to the vertical. Steel wire rope gripes pass over these bollards. Each 14 mm-diameter gripe has a breaking strain of 13000kg - a load far exceeding the total weight of the lifeboat and its contents. The gripe is intended to hold the lifeboat hard-up against the davit frame and to prevent the lifeboat from hitting the frame in a seaway. One end of each gripe is secured to a pad eye that is welded to the ship's deck; the other end passes over a freely rotating hooked lever that is attached to the side of the davit. Photo7. After bollard, gripe and hook lever on davit Photo8. Forward view of lifeboat, showing davit, gripe arrangement around bollards, suspension ring, hook and hatch In the lifeboat's stowed position, the free end of this rotating lever bears against the rigid support frame of the davit, preventing it from turning. 1.1.5 Lifting Hooks and their Release Mechanism Photo9. View of hook, suspension ring, and retaining latch The lifting hooks are of the on-load/off-load release type. They are designed so that they can be opened simultaneously to release the lifeboat, either when it is out of the water and its weight is suspended from the falls or when the lifeboat is floating on the water and there is no weight on the falls. The hook assembly consists of the two side cheek plates, which form the frame to which attach the hook, the blocking lever, the reset lever, and the retaining latch (see Figure 6). These components all have holes drilled through them and are connected to the cheek plates via small shafts that pass through the components and the corresponding holes in the cheek plates. In the assembled arrangement, the parts are free to individually rotate about their shafts. The entire assembly is made of galvanized mild steel. In the load-bearing or reset condition of the hook assembly (seePhotograph10), the flat end of the hook bears against and transmits a load onto the blocking lever, which in turn rests against a cam profile on the reset lever. At its contact surface with the hook, the blocking lever has a relief angle of 18. As long as the reset lever remains in a position where its cam prevents the blocking lever from rotating downward, the hook remains locked and can carry its portion of the designed weight of the lifeboat and its contents (seePhotograph10). Photo10. View of hook in load-bearing (reset) condition 1.Hook, 2.Blocking lever, 3.Reset lever At its free end, the reset lever carries a clevis joint to which is attached a teleflex cable. The other end of this cable is similarly fixed to a cable connection arm which, in turn, is fitted inside the central release control assembly (seeFigure3). The functioning parts of the forward and after hooks are identical. Both hooks are mounted on the lifeboat in such a way that their orientation is in the same direction, facing aft. On each hook assembly, the hook, the blocking lever, and the reset lever carry reference marks. The cheek plates have corresponding reference marks. The hook has been correctly reset when these marks are properly aligned. The TSB's post-occurrence inspection of the hook assemblies indicated that, in the reset position, the reference marks on the reset levers were not aligned with the reference marks on the cheek plates. The top surface of the mark on the reset lever was just below the bottom surface of the marks on the cheek plates (seePhotograph20). Photo11. View of hook in open condition 1.1.6 Central Release Control Assembly Figure3. View showing connection between central release control assembly and hooks The central release control assembly is just behind and to port of the coxswain's seat (seePhotograph12). It is made of two galvanized steel side plates to which are connected the release lever, the cable connection arms, and the interlock lever. A solenoid coil is mounted on top of the framework formed by the side plates. Photo12. Central release control assembly. The release lever is essentially a bell crank lever. One end of the lever forms the actual release handle; the other (free) end has two pins attached to it at right angles to its plane. These pins bear against the cable connection arms, which are connected to and rotate about the same shaft as the release lever. Pulling on the release handle allows these pins to lift the cable connection arms. The free movement of the release handle can be blocked by a safety pin, which is hinged at a point on one side plate and fits in a slot on the other side plate. The interlock lever, also shaped like a bell crank, turns about its own shaft but in the same plane as the release lever and the cable connection arms. A mechanical linkage connects the interlock to a solenoid coil above it; a return spring is connected to the interlock lever from underneath. The interlock lever can swing into, or out of, a position where it blocks the upward travel of the cable connection arms and, thereby, the release handle. The free end of the interlock lever is enclosed in a housing, one side of which is covered by a clear Perspex removable window that faces the operator. In an emergency, the operator can remove the window and manually lift the interlock lever away from its blocking position. According to the instruction manual, the frame around the perspex window is painted in two colours: the top half is red and the bottom part green. When inspected by the TSB, the entire frame was found to be painted red. Figure4. Internal schematic of central release control assembly The two cable connection arms are connected to reset levers on the forward and after hook assemblies via teleflex cables in such a way that they form an inflexible structure. When the cable connection arms move upward, under the action of the release handle, the reset levers are forced to move downward. The central release control assembly houses three microswitches: two make contact with the two cable connection arms; the third is beneath the interlock lever with which it makes contact. The microswitches are used to indicate various operating conditions at the electrical alarm and control panel (seeSection1.1.8). 1.1.7 Water-Pressure Switch. (Hydrostatic Interlock.) A pressure switch is fitted on the keel of the lifeboat. This switch senses whether the lifeboat is in or out of the water and transmits a corresponding electrical signal to the solenoid coil fitted over the interlock lever. Essentially, this switch consists of a diaphragm that flexes under the influence of hydrostatic pressure and thereby makes or breaks an electric contact, which in turn energizes or de-energizes the solenoid. The chamber above the diaphragm is maintained at atmospheric pressure by means of an equalising vent connection. 1.1.8 Pressure Switch and Alarm Light Control Box (Indication Panel) 1.1.9 Description of a Typical Lifeboat Launch and Recovery To launch a lifeboat, the harbour pins are first removed. This effectively removes all mechanical restraints on the davits, which are now held in position by the tension in the falls as they are turned up on the winch drum, which is held fast by its brake. The next step is to remove the stopper pin above the dead man's handle, which is connected to the winch brake. When the handle is lifted up, it disengages the brake, thus allowing the winch drum to rotate and the falls to pay out. The davits turn about their hinge pins. As the davits move away from their support frames, the hooked levers (seePhotograph7) rotate and release the free ends of the gripes, which then fall away. The davits continue moving outboard of the ship, and the lifeboat swings out until it is clear of the ship's side. The floating blocks come free of the horns on the davits, and the full weight of the lifeboat is transferred to the falls. The stops on the davit frames halt further outward movement of the davits, and the lifeboat continues its descent into the water, suspended from the falls. Once the lifeboat is floating on the water, the hooks are opened from inside the lifeboat by pulling on the central release handle. The suspension rings are now freed from the hooks, and the lifeboat can move away from the ship. To reconnect the lifeboat to the falls, the forward and after hooks first have to be reset. The lifeboat is then manoeuvred and brought under the floating blocks, and the suspension rings are slipped into the hooks. The retaining latch prevents the suspension ring from slipping out when there is no load on the falls. An electric winch hoists the lifeboat back up, until the floating blocks bear against the davit heads. As the winch continues to haul in the falls, the davit arms are forced to come off their stops and move inboard. This change in their angular disposition allows the davit horns to re-enter the floating blocks and also allows the lifeboat to move towards, and back into, its stowage position. The davits and the lifeboat are then secured by re-engaging the harbour pins and reconnecting the gripes. Slackening off the tension in the falls now has the effect of lowering the floating blocks until the weight of the lifeboat is transferred to the davit horns. 1.1.10 Procedure for Resetting the Hooks Figure5. Arrangements of reference marks on hook assembly The central release handle is first returned to its original (reset) position. The handle's bell crank lever thus moves away from the cable connection arms, allowing them to be pulled down when the reset levers are pushed up. Each hook is turned until the red line painted on its side lines up with the cheek plate. The hook is held in this position with the right hand, while the left hand turns the blocking knob anticlockwise, until the reference arrow attached to it comes into alignment with a corresponding arrow on the cheek plate. The blocking knob is now held fast by the left hand, and the right hand pulls up the cable reset lever until it lines up with its own reference marks on the cheek plates. Once this has been done correctly, the safety pin in the central release control assembly is inserted into its slot and the release handle locked. 1.1.11 Lifejackets, Seats, and Seatbelts in the Lifeboats The lifejackets complied with SOLAS requirements. In accordance with the relevant SOLAS regulations, the lifeboat was fitted with safety seatbelts at each seating position. The following items of note were found on the Pacmonarch's two lifeboats: Many of the nuts securing the seatbelts to the shell were very loose on the port and starboard lifeboats. With the exception of a foam headrest, the seating area has no protective padding. Although the lifeboat had been designed for a free fall from a height of 3m, no measure had been taken to soften the effect of the impact on the occupants of the lifeboat. A crew member wearing the supplied lifejacket would have had about 105mm of hard flotation material (designed to support the wearer's neck in the water) protruding behind his/her neck. When seated at a designated seating area along the sides of the lifeboat, s/he would have another 55mm of foam headrest, as well as the inwardly sloping roof of the lifeboat, bearing against this portion of the lifejacket and pushing his/her neck forward. 1.1.12 Operating Instructions and Training Requirements for the Lifeboat The operations manual, which is written in English, describes in detail the procedures to release the hooks and to reset them before recovery of the lifeboat. The steps required to release the hooks are also set out on a placard mounted inside the lifeboat, beside the indication panel. These steps are written in English, in the form of a flowchart showing on-load and off-load release procedures. Information on the resetting procedure is not posted inside the lifeboat. A diagram of the three indicators (cable reset lever, hook position, and blocking knob), used while resetting the hooks, is also inside the lifeboat on the bulkhead adjacent to the forward and after hatches. However, the diagram has no text to indicate the correct procedures to follow. The language of the crew was Ukranian, and not many of them were familiar with English. Both the captain and the chief officer spoke and understood written English. The ship had in place a safety management system. Accordingly, both lifeboats had been launched three or four times since the delivery of the Pacmonarch. The crew had also conducted periodic lifeboat drills and was sufficiently trained in the procedures for launching the lifeboat. 1.2 History of the Voyage The vessel was built in Sasebo, Japan, and delivered to its owners in July2000. After making two voyages to Australia, the Pacmonarch sailed on a ballast voyage to Vancouver, British Columbia, arriving at about 03002 on 19October2000. It anchored at English Bay anchorage, waiting at a berth to load a cargo of grain. During this period at anchor, the vessel's crew used the two lifeboats for trips ashore and to another vessel anchored nearby. The port lifeboat was used on October24 without incident. At about 1045 on October26, the crew of the Pacmonarch started to launch the port lifeboat for an ordinary run ashore. The second officer, accompanied by the third assistant engineer and two seamen, boarded the lifeboat and prepared it from the inside, while the chief officer and another seaman removed the external securing arrangements. The plan was to lower the lifeboat to the lifeboat deck, where the rest of the shore party would board it. The lifeboat is designed to be boarded from the embarkation platform and is not equipped with bowsing gear to pull it alongside the ship. However, when lowered to a level where the side hatch is nearly flush with the lifeboat deck, it can also be boarded from this location. The chief officer and the second officer were using handheld radio sets to communicate. The second officer sat in the coxswain's seat in the lifeboat's conning tower; the engineer sat behind him on the outboard (port) side of the lifeboat. A seaman was positioned at the forward hatch and another at the after hatch, near the hooks. The lifeboat's occupants all wore buoyant work vests and hard hats but did not attach their seatbelts, nor were they required to. The second officer informed the chief officer that pre-launch checks had been carried out and that everything was in order. At this time, the chief officer was standing on the embarkation platform and facing the lifeboat. The seaman on the lifeboat deck was standing at the bow of the lifeboat. Upon receiving the chief officer's permission to lower the lifeboat, the second officer pulled the winch-brake remote-release cable to disengage the winch brake. The davits turned out smoothly and the lifeboat swung to the ship's side easily and without jerking. During the launch sequence and soon after the davits hit their stops, when the lifeboat was about 1.5 to 2.0m below the davit head, the lifeboat became inclined, bow down, at about 40 to the horizontal. The after suspension ring then separated from its hook, damaging the retaining latch. The lifeboat then swung about the forward hook, which opened and released the forward suspension ring. Completely free, the lifeboat plummeted stern first into the sea. The lifeboat became almost vertical (without ever actually going past vertical) before it hit the water. The impact considerably damaged the stern of the canopy. The hatches were open and water flooded into the lifeboat. As a result, the lifeboat lost its self-righting ability and floated with its starboard side submerged. The master, upon hearing of the accident, rushed to the vessel's bridge and broadcast a Mayday. A tug and a water taxi were attending a ship at an adjacent anchorage. Hearing the broadcast, they rushed to the rescue and arrived on the scene first. The seaman, stationed by the forward hatch, had managed to crawl back to it. He was seen by the crew and lifted out to safety. There was an experienced diver on board one of the boats and, though unequipped with proper diving gear, he nevertheless entered the lifeboat to try and extricate the others. He found them unconscious, surrounded by the debris of the boat's fall and lying in the water that was entering the boat. The diver managed to reach one of the crew and, assisted by other rescuers, pulled him out. By this time, a Canadian Coast Guard rescue vessel had reached the scene. Its diving team started cutting the partially broken stern section of the canopy to increase the opening. They were thus able to remove the lifeboat's remaining two occupants. Although the Coast Guard administered first aid and rushed the victims to hospital for treatment, three of the four men on board the lifeboat did not recover consciousness and succumbed to their injuries. Because of concern that the lifeboat might sink, attempts were made to reattach the hooks to the falls and to lift it clear of the water. These attempts were unsuccessful and the lifeboat was towed to the Kitsilano Coast Guard base. 1.3 Description of a Similar Accident On 06August2000, the crew of the Washington Trader, a sister vessel of the Pacmonarch, was carrying out a training launch of its port lifeboat at Abbot Point, Queensland, Australia. In very similar circumstances, the lifeboat separated from its after falls and swung about the forward hook, which also opened. The lifeboat then fell stern first into the sea. The damage to the two lifeboats was almost identical, including the damage to the retaining latch on the after hook. Because no one was in the Washington Trader's lifeboat and there was no urgent need to rescue trapped people, the master of the vessel was able to preserve the lifeboat as is. Investigators of the Australian Transport Safety Bureau found the after hook to be in the closed or reset condition and the forward hook to be open.3 1.4 Injuries to Persons 1.5 Damage 1.5.1 Damage to the Lifeboat Photo14. Damage to the stern of the lifeboat Photo15. Damage to the stern of the lifeboat Photo16. Damage to the after retaining latch The impact with the water caused considerable damage to the stern of the lifeboat, with most of the damage concentrated around the canopy. The vertical panel was pushed inward, and the glass-reinforced plastic was torn right through. During rescue operations, divers further cut this torn opening and folded back the entire vertical panel, giving them unhindered access to the inside of the lifeboat (seePhotograph14,15). Inside the lifeboat, the coxswain's chair and the frame of the central release control assembly were attached to the after bulkhead. The chair's support frame was badly buckled and broken and the control assembly frame's brackets were found to be completely broken off. The horizontal part of the canopy (onto which the after hook assembly, the towing bracket, and the other attachments were fixed) was bent upward. Portions of the canopy were torn and bolts securing the canopy to the hull were also broken. Other internal damage consisted of bent rudder linkages, holding-down brackets, and holding-down frames. 1.5.2 Damage to Hook Assemblies and Suspension Rings The retaining latch on the after hook assembly was damaged in such a way that its two vertical forked arms were both bent sideways and outboard of the lifeboat (seePhotograph16). The after hook was not damaged, but had scoring marks on its inside surface in the area that comes .in contact with the suspension ring. The after suspension ring was not damaged but did have two small scoring marks on the outside bottom surface in an area that comes in line with the forked arms of the retaining latch (seePhotograph17). The forward hook assembly and its suspension ring were not damaged. Photo17. Scoring marks on the suspension ring Photo18. Scoring marks on the suspension ring 1.5.3 Damage to Davits, Winch, Frames, Floating Blocks, and Falls The davits, davit winch, and davit frames were not damaged; neither were the floating blocks or the falls. Paint at the joint between the winch foundation plate and the frame was found chipped and broken. The rest of the paint was intact. 1.6 Certification 1.6.1 Vessel The Pacmonarch was certificated according to the requirements for a vessel of its class and type. The certificates were all valid and current. 1.6.2 Personnel The officers and the crew on board were properly certificated and met the requirements of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1995. 1.7 Testing of the Starboard Lifeboat The day after the accident, and on subsequent dates, the starboard lifeboat was launched several times. The launchings were videotaped, and the tape later analyzed. At each launching, the forward and after gripes fell free of the davit, but turned up on and temporarily became fouled on the lifeboat's bollards before the floating block cleared the horns on the davits.